HHS announces first guidance implementing Supreme Court’s decision on the Defense of Marriage Act

Today, the Department of Health and Human Services (HHS) issued a memo clarifying that all beneficiaries in private Medicare plans have access to equal coverage when it comes to care in a nursing home where their spouse lives.  This is the first guidance issued by HHS in response to the recent Supreme Court ruling, which held section 3 of the Defense of Marriage Act unconstitutional.

“HHS is working swiftly to implement the Supreme Court’s decision and maximize federal recognition of same-sex spouses in HHS programs,” said HHS Secretary Kathleen Sebelius.  “Today’s announcement is the first of many steps that we will be taking over the coming months to clarify the effects of the Supreme Court’s decision and to ensure that gay and lesbian married couples are treated equally under the law.”

“Today, Medicare is ensuring that all beneficiaries will have equal access to coverage in a nursing home where their spouse lives, regardless of their sexual orientation,” said Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner.  “Prior to this, a beneficiary in a same-sex marriage enrolled in a Medicare Advantage plan did not have equal access to such coverage and, as a result, could have faced time away from his or her spouse or higher costs because of the way that marriage was defined for this purpose.”

Under current law, Medicare beneficiaries enrolled in a Medicare Advantage plan are entitled to care in, among certain other skilled nursing facilities (SNFs), the SNF where their spouse resides (assuming that they have met the conditions for SNF coverage in the first place, and the SNF has agreed to the payment amounts and other terms that apply to a plan network SNF).  Seniors with Medicare Advantage previously may have faced the choice of receiving coverage in a nursing home away from their same-sex spouse, or dis-enrolling from the Medicare Advantage plan which would have meant paying more out-of-pocket for care in the same nursing home as their same-sex spouse.

Today’s guidance clarifies that this guarantee of coverage applies equally to all married couples.  The guidance specifically clarifies that this guarantee of coverage applies equally to couples who are in a legally recognized same-sex marriage, regardless of where they live.
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“Profit-Motive” Is Negatively Impacting Your Healthcare: Medicare Provider Charge Data

As part of the Obama administration’s work to make our health care system more affordable and accountable, data are being released by HHS (Health & Human Services) that show significant variation across the country, even within communities as to what hospitals charge for common inpatient services.

“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” Secretary Sebelius said. “This data and new data centers will help fill that gap.”  For example,

  • In Dallas, Las Colinas Medical Center billed Medicare an average of $160,832 for a lower joint replacement. The price was $42,632 five miles away, at Baylor Medical Center.
  • Average inpatient charges for services for a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.
  • Average inpatient hospital charges to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.
  • Ventilator: $115,00 George Washington University vs. $53,000 at Providence (just 5.4 miles apart)
  • Lower limb replacement: $117,000 at Richmond CJW Medical Center vs. 25,600 at Winchester Medical Center
  • Pneumonia: $124,051 in Philadelphia vs. $5,093 in Water Valley, Mississippi.

According to Ron Pollack, executive director of Families USA, hospital pricing is “the craziest of crazy quilts.” He went on to say, “It is absurd — and, indeed, unconscionable — that the people least capable of paying for their hospital care bear the largest, and often unaffordable, cost burdens.”

Medicare has begun paying providers based on quality rather than just the quantity of services they furnish by implementing new programs, such as value-based purchasing and re-admissions reductions.  HHS awarded $170 million to states to enhance their rate review programs, and since the passage of the Affordable Care Act (ACA), the proportion of insurance company requests for double-digit rate increases fell from 75 percent in 2010 to 14 percent so far in 2013.

The ACA also makes available many tools to help ensure consumers, Medicare, and other payers get the best value for their health care dollar.  To make data from these tools useful to consumers, HHS is also providing funding  to data centers to collect, analyze, and publish health pricing and medical claims reimbursement data.  The data centers’ work helps consumers better understand the comparative price of procedures in a given region or for a specific health insurer or service setting. Businesses and consumers alike can use these data to drive decision-making and reward cost-effective provision of care.

Data are available in Microsoft Excel (.xlsx) format and comma-separated values (.csv) format.

Inpatient Charge Data, FY2011, Microsoft Excel version
Inpatient Charge Data, FY2011, Comma Separated Values (CSV) version

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service. The Total Payment amount includes a Medicare Severity Diagnosis Related Group (MS-DRG) amount, bill total per diem, beneficiary primary payer claim payment amount, beneficiary Part A coinsurance amount, beneficiary deductible amount, beneficiary blood deducible amount and DRG outlier amount.

Data provided by CMS (Centers for Medicare/Medicaid Services) include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the MS-DRG for FY2011.

DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges. Average charges and average Medicare payments are calculated at the individual hospital level. Users will be able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.

There is some debate about how much patients, insurance providers and the government actually end up paying. “It’s true that Medicare and a lot of private insurers never pay the full charge,” said assistant professor at the University of California at San Francisco Medical School, Renee Hsia, “You have a lot of private insurance companies where the consumer pays a portion of the charge. But, for uninsured patients, they face the full bill. In that sense, the price matters.”

To view the new hospital dataset, please go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html.

To access the funding opportunity announcement, visit: http://www.grants.gov, and search for CFDA # 93.511.

For more information on HHS efforts to build a health care system that will ensure quality care, please see the fact sheet “Lower Costs, Better Care: Reforming Our Health Care Delivery System,” athttp://www.cms.gov/apps/media/press/factsheet.asp?Counter=4550.

To read a fact sheet about the Medicare data showing variation in hospital charges, please see:http://www.cms.gov/apps/media/fact_sheets.asp.

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Medicare Fraud Task Force Nets $452M

OR IMMEDIATE RELEASE
May 2, 2012
Contact: HHS Press Office
(202) 690-6343

Medicare Fraud Strike Force charges 107 individuals for approximately $452 million in false billing

Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder announced today that a nationwide takedown by Medicare Fraud Strike Force operations in seven cities has resulted in charges against 107 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $452 million in false billing.

Attorney General Holder and Secretary Sebelius were joined in the announcement by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division, Federal Bureau of Investigations (FBI) Deputy Director Sean Joyce, Deputy Inspector General for Investigations Gary Cantrell of the HHS Office of Inspector General (HHS-OIG) and Dr. Peter Budetti, Deputy Administrator for Program Integrity of the Centers for Medicare & Medicaid Services (CMS).

This coordinated takedown involved the highest amount of false Medicare billings in a single takedown in Strike Force history.

HHS also suspended or took other administrative action against 52 providers following a data-driven analysis and credible allegations of fraud.  The new health care law, the Affordable Care Act, significantly increased HHS’ ability to suspend payments until an investigation is complete.

The joint Department of Justice and HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques.  More than 500 law enforcement agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the takedown.  In addition to making arrests, agents also executed 20 search warrants in connection with ongoing Strike Force investigations.

“The results we are announcing today are at the heart of an administration-wide commitment to protect American taxpayers from health care fraud, which can drive up costs and threaten the strength and integrity of our health care system,” said Attorney General Holder.  “We are determined to bring to justice those who violate our laws and defraud the Medicare program for personal gain.  As today’s takedown reflects, our ongoing fight against health care fraud has never been more coordinated and effective.”

“Today’s arrests send a strong message to criminals that the consequences of committing Medicare fraud are serious,” said HHS Secretary Sebelius.  “In addition to these arrests, we used new authority from the health care law to stop all future payments to 52 health care providers suspected of fraud before they are ever made.  Today’s actions are another example of how the Affordable Care Act is helping the Obama administration fight fraud and strengthen Medicare.”

The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering.  The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided.  In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $452 million in fraudulent billing.

“As charged in the indictments, these fraud schemes were committed by people up and down the chain of health care providers,” said Assistant Attorney General Breuer.  “Today’s operations mark the fourth in a series of historic Medicare fraud takedowns over the past two years.  These indictments remind us that Medicare is an attractive target for criminals.  But it should also remind those criminals that they risk prosecution and prison time every time they submit a false claim.”

“Health care fraud is not a victimless crime,” said FBI Deputy Director Joyce.  “Every person who pays for health care benefits, every business that pays higher insurance costs to cover their employees, every taxpayer who funds Medicare—all are victims.  The FBI will continue to work closely with our federal, state and local law enforcement partners to address health care vulnerabilities, fraud and abuse.  We will use every tool we have to ensure our health care dollars are used to care for the sick—not to line the pockets of criminals.”

“Today more than 200 OIG Special Agents, Forensic Examiners and Analysts have deployed throughout the country to ensure that those responsible for committing Medicare fraud are held accountable,” said HHS-OIG Deputy Inspector General Cantrell.  “OIG is committed to the strike force model and will continue to use advanced data analytics along with traditional investigative methods to root out those who steal from our Medicare program.”

In Miami, a total of 59 defendants, including three nurses and two therapists, were charged today and yesterday for their participation in various fraud schemes involving a total of $137 million in false billings for home health care, mental health services, occupational and physical therapy, DME and HIV infusion.  Two of these 59 defendants were originally charged in April 2012 but were indicted on additional charges today.  In one case, 10 defendants were charged for participating in a fraud scheme at Health Care Solutions Network, which led to approximately $63 million in fraudulent billing for community mental health center (CMHC) services.  Court documents allege that therapists at Health Care Solutions Network were instructed to alter notes and other medical documents to justify CMHC services for beneficiaries who did not need the services.

Seven individuals were charged today in Baton Rouge, La., for participating in a fraud scheme involving $225 million in false claims for CMHC services.  The case represents the largest CMHC-related scheme ever prosecuted by the Strike Force.  According to court documents, the defendants recruited beneficiaries from nursing homes and homeless shelters, some of whom were drug addicted or mentally ill, and provided them with no services or medically inappropriate services.

In Houston, nine individuals, including one doctor and one nurse, were charged today with fraud schemes involving a total of $16.4 million in false billings for home health care and ambulance services.  According to court documents, the owners and operators of four different ambulance companies billed Medicare for ambulance rides that were medically unnecessary.

Eight defendants, including two doctors, were charged in Los Angeles for their roles in schemes to defraud Medicare of approximately $14 million.  In one case, two individuals allegedly billed Medicare for more than $8 million in fraudulent billing for DME.

In Detroit, 22 defendants, including four licensed social workers, were charged for their roles in fraud schemes involving approximately $58 million in false claims for medically unnecessary services, including home health, psychotherapy and infusion therapy.

In Tampa, Fla., a pharmacist was charged with illegal diversion of controlled substances.  One defendant was charged last week in Chicago for his alleged role in a scheme to submit approximately $1 million in false billing to Medicare for psychotherapy services.

The Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Since their inception in March 2007, Strike Force operations in nine locations have charged more than 1,330 defendants who collectively have falsely billed Medicare for more than $4 billion.  In addition, the CMS, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The cases announced today are being prosecuted and investigated by Strike Force teams comprised of attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorneys’ Offices for the Southern District of Florida, the Eastern District of Michigan, the Southern District of Texas, the Central District of California, the Middle District of Louisiana, the Northern District of Illinois, and the Middle District of Florida, and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units.

An indictment is merely a charge and defendants are presumed innocent until proven guilty.

To learn more about HEAT, go to: www.stopmedicarefraud.gov.

Affordable Care Act Saves $2.1B for 3.6 million Americans with Medicare

FOR IMMEDIATE RELEASE
February 2, 2012
Contact: CMS Public Affairs
(202) 690-6145


New data show average American with Medicare to save nearly $4,200 through 2021 thanks to health reform

Nearly 3.6 million people with Medicare saved $2.1 billion on their prescription drugs in 2011 thanks to the Affordable Care Act according to data issued today by the Department of Health and Human Services (HHS). Savings for people with Medicare will increase over time. According to a new report issued today from HHS, the average person with Medicare will save nearly $4,200 by 2021 because of the new law.

“The Affordable Care Act is already saving money for millions of Americans with Medicare,” said HHS Secretary Kathleen Sebelius.  “As we move forward, we will close the donut hole completely and save even more money for everyone with Medicare.”

The Affordable Care Act provides a 50 percent discount on brand-name prescription drugs and this year, a 14% discount on generics. Last year, it provided a seven percent discount on covered generic medications for people who hit the prescription drug coverage gap known as the donut hole, with 2,814,646 beneficiaries receiving $32.1 million in savings on generics.

In 2011, the 3.6 million Americans who hit the donut hole saved an average of $604 on the cost of their prescription drugs.

Data also show that women especially benefitted from the law’s provision with 2.05 million women saving $1.2 billion on their prescription drugs.

By 2020, the donut hole will be closed completely.  The new report released today by the Department of Health and Human Services finds that this provision and other features of the health reform law will generate substantial savings for people with Medicare. Typical Medicare beneficiaries will save an average of nearly $4,200 from 2011 to 2021. People with high prescription drug costs could save as much as $16,000.

The savings are a product of provisions in the Affordable Care Act and other cost trends that:

  • Decrease prescription drug costs for seniors
  • Make preventive services like mammograms free for everyone in Medicare
  • Reduce growth in Part B premiums (for physician services)
  • Reduce growth in cost-sharing under both Parts A (hospital care) and Part B.

These announcements come one day after HHS announced that in 2012, Medicare Advantage premiums have fallen by seven percent on average and enrollment has risen by about 10 percent since last year.  For more details on that announcement, visit http://www.hhs.gov/news/press/2012pres/02/20120201a.html

For state-by-state savings figures for today’s donut hole announcement, visit: http://www.cms.gov/Plan-Payment/

For a fact sheet about donut hole savings, visit http://www.cms.gov/apps/media/fact_sheets.asp

For the report regarding savings those with Medicare will see over time, visithttp://aspe.hhs.gov/hp/reports/2012/MedicareBeneficiarySavings/ib.shtml

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